Primary and Secondary Syphilis — United States, 2005–2013

In 2013, based on data reported as of April 28, 2014, the rate of reported primary and secondary syphilis in the United States was 5.3 cases per 100,000 population, more than double the lowest-ever rate of 2.1 in 2000. To characterize the recent epidemiology of syphilis in the United States, CDC analyzed data from the National Notifiable Diseases Surveillance System (NNDSS) for cases of primary and secondary syphilis diagnosed during 2005-2013 with a focus on states that reported the sex of sex partners during 2009-2012 to describe reported syphilis among gay, bisexual, and other men who have sex with men (collectively referred to as MSM). During 2005-2013, primary and secondary syphilis rates increased among men of all ages and races/ethnicities across all regions of the United States. Recent years have shown an accelerated increase in the number of cases, with the largest increases occurring among MSM. Among women, rates increased during 2005-2008 and decreased during 2009-2013, with different trends among different racial/ethnic groups. Racial/ethnic disparities in reported syphilis persisted during 2005-2013, likely reflecting social determinants of health, such as socioeconomic status, that might contribute to the burden of syphilis in a community. These findings underscore the need for continued syphilis prevention measures among MSM.

In 2013, based on data reported as of April 28, 2014, the rate of reported primary and secondary syphilis in the United States was 5.3 cases per 100,000 population, more than double the lowest-ever rate of 2.  (1). These findings underscore the need for continued syphilis prevention measures among MSM.
CDC analyzed notifiable disease surveillance data on reported syphilis, including patient demographics and stage of syphilis (i.e., primary and secondary, early latent, late, late latent, and congenital*) reported by health departments to NNDSS nationwide for cases diagnosed during 2005-2013. Trends in annual primary and secondary syphilis (representing more recently acquired infections, which usually are infectious) were analyzed for 2005-2013. Geographic trends were analyzed by U.S. census region, age group, and NNDSS racial/ethnic categories (white, black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native, for which all racial groups were non-Hispanic). In addition, to describe syphilis among MSM, annual cases of primary and secondary syphilis among MSM that were reported during 2009-2012 were reviewed from 34 states and the District of Columbia, where the sex of sex partners was reported for ≥70% of male primary and secondary syphilis cases (CDC began collecting data on the sex of sex partners in 2005). Rates were calculated using population denominators from the U.S. Census Bureau.
During 2005-2013, the number of primary and secondary syphilis cases reported each year in the United States nearly doubled, from 8,724 to 16,663; the annual rate increased from 2.9 to 5.3 cases per 100,000 population (Table). Men contributed an increasing proportion of cases, accounting for 91.1% of all primary and secondary syphilis cases in 2013. The rate among men increased from 5.1 in 2005 to 9.8 in 2013 ( Figure 1 (Table).
In 2012, primary and secondary syphilis cases in the 35 reporting areas that reported the sex of sex partners for ≥70% of male cases comprised 83.7% (13,113) of all nationwide cases. In those areas, the proportion of male primary and secondary syphilis cases attributed to MSM increased from 77.0% (6,366)     Racial/ethnic disparities in syphilis persisted. In 2013, the primary and secondary syphilis rate among black men was 5.2 times that among white men (27.9 versus 5.4 cases per 100,000 population); the rate among black women was 13.3 times that among white women (4.0 versus 0.3). The rate among Hispanic men was 2.1 times that among white men (11.6 versus 5.4), and the rate among Hispanic women was 2.7 times that among white women (0.8 versus 0.3). These disparities were similar to disparities observed in 2005 (Table).
Across all four U.S. Census regions, primary and secondary syphilis rates were greater in 2013 than in 2005. In 2013, the highest overall regional rate (6.5 cases per 100,000 population) was in the West region. In 2013, for the first time in at least 50 years, the South did not have the highest overall syphilis rate among regions. Regional trends among men and women by race/ethnicity mirrored national trends except in the West region, where there was no decrease among black men during 2009-2013. Among women of all races/ethnicities in the West region, rates declined during 2005-2010 and increased during 2011-2013 (Table). The epidemiology of syphilis among men, including MSM, has shifted since 2009, with larger increases occurring among Hispanic and white men. Despite this increase, disparities in primary and secondary syphilis between black men and other racial/ethnic groups remain large. Many barriers to contacting and treating sex partners exist, including delays in reporting cases to the health department, anonymous partners, physicians who rely on patients to notify their partners (2), and the observed tendency of MSM to notify a smaller proportion of their sex partners than do heterosexuals (3). These analyses indicate that syphilis prevention measures for MSM of all races/ethnicities need to be strengthened throughout the United States. This could be accomplished by working with private health-care providers because a substantial number of primary and secondary syphilis cases among MSM are reported by private physicians (1). Further, both private and Total public providers should be aware of the resurgence in syphilis and should be able to recognize the signs and symptoms of syphilis, conduct risk assessments, and screen all sexually active MSM for syphilis at least annually with syphilis serologic tests with confirmatory testing where indicated (4). More frequent screening (i.e., at 3-6 month intervals) is recommended for MSM who have multiple or anonymous sex partners. Disclosure of sexual practices remains difficult for some MSM (5); therefore, providers are encouraged to elicit sexual histories of their patients in a culturally appropriate manner, including recognition of sexual orientation, gender identity, and the sex of patients' sex partners. Additional resources and training for accomplishing this are available online. † The increase in syphilis among MSM is a major public health concern, particularly because syphilis and the behaviors associated with acquiring it increase the likelihood of acquiring and transmitting human immunodeficiency virus (HIV) (6). There are reported rates of 50%-70% HIV coinfection among MSM infected with primary and secondary syphilis (7) and high HIV seroconversion rates following primary and secondary syphilis infection (8). The resurgence of syphilis, coupled with its strong link with HIV, underscores the need for programs and providers to 1) urge safer sexual practices (e.g., reduce the number of sex partners, use latex condoms, and have a long-term mutually monogamous relationship with a partner who has negative test results for sexually transmitted diseases); 2) promote syphilis awareness and screening as well as appropriate screening for gonorrhea, chlamydia, and HIV infection; and 3) notify and treat sex partners.

Discussion
Public health officials should seek to improve the quality of data regarding the sex of sex partners, share local MSM, sexually transmitted disease, and HIV data consistent with local laws and regulations with medical providers to increase their awareness of disease burden in their communities, and ensure that providers can recognize syphilis symptoms. Two CDC cooperative agreements are encouraging local and state participants to make MSM a priority population and direct resources to areas of greatest need based on local epidemiology (9,10). CDC, in collaboration with state and local partners, health-care providers, and MSM-oriented organizations, is also engaged in research to better understand risk factors for syphilis among MSM, develop improved care models to better reach  and serve MSM populations, assess whether MSM are being tested and treated appropriately, and determine what barriers exist in the diagnosis and treatment of syphilis among MSM. The continued decline of primary and secondary syphilis rates among black women since 2008 is encouraging and might suggest that targeted efforts to reduce syphilis among certain populations have had some success. Although primary and secondary syphilis is currently a predominantly MSM epidemic, it is important that efforts to prevent syphilis among heterosexual men and women continue, especially given the severe consequences of syphilis infection acquired in utero, including stillbirths.
The findings in this report are subject to at least two limitations. First, primary and secondary syphilis case-report data likely underestimate the true number of syphilis infections in the United States because of underreporting of diagnosed cases, infected persons not accessing health care, misdiagnosis, and the fact that primary and secondary syphilis cases amounted to only 31.4% of all syphilis cases reported in 2012. Second, the findings for MSM included only data from 34 states and the District of Columbia, where the sex of sex partners was reported for 70% or more of male primary and secondary syphilis cases. For 12% of cases in these 35 reporting areas, the sex of sex partners was unknown.
Despite decreasing rates of primary and secondary syphilis in the late 1990s in the United States, the resurgence of cases in recent years highlights the fact that challenges remain, and the increases among MSM are particularly concerning. Public health practitioners might want to consider focusing on efforts to strengthen linkages with practicing physicians to improve case identification and reporting, partner-notification programs, and outreach to MSM.